Abstract

Malaysia has achieved reasonable health outcomes even though the country spends a modest amount of Gross Domestic Product on healthcare. However, the country is now experiencing a rising incidence of both infectious diseases and chronic lifestyle conditions that reflect growing wealth in a vibrant and successful economy. With an eye on an ageing population, reform of the health sector is a government priority. As in other many parts of the world, general practitioners are the first healthcare professional consulted by patients. The Malaysian health system is served by public and private care providers. The integration of the two sectors is a key target for reform. However, the future health of the nation will depend on leadership in the primary care sector. This leadership will need to be informed by research to integrate care providers, empower patients, bridge cultural gaps and ensure equitable access to scarce health resources.

Keywords

chronic disease, healthcare, Malaysia, primary care

It is imperative that the increasing magnitude
of chronic disease burden is anticipated, understood and acted upon urgently.
Chronic disease prevention and control can no longer be ignored as an important
means of economic development.[1]

The proportion
of the world’s population that cur-rently lives in China and India has been
estimated to be 36.5%.[2,3] By also factoring in the populations of
Indonesia, Pakistan and Bangladesh, one may con-clude that the majority of the
world’s people live in Asia. Therefore, health innovations that could improve health in
Asia would serve most of the world’s people. For example, according to the
World Health Organization, South East Asia has the highest number of new cases
of tuberculosis and measles in the world; it also has the highest incidence of
congestive heart failure due to rheumatic heart disease, hypertensive heart
disease, ischaemic heart disease or inflammatory heart disease.[4]
This paper explores the scope to design solutions to Asian healthcare
challenges using Malaysia as an exemplar.

Malaysia

Malaysia is the
southern gateway to Asia, its territory straddling the Asian mainland and the
Malay archi-pelago. There are two distinct parts to the country, east
(Peninsular) Malaysia and the west. Malaysia shares land borders with Thailand,
Indonesia and Brunei, and maritime borders with Singapore, Vietnam and the
Philippines. In 2010, the population exceeded 27.5 million. The Malaysia of
today is a highly successful market economy.[5] It is weathering the
global financial crisis better than many countries in Europe. Per capita gross
domestic product (GDP) makes it the third largest economy in the Asscoiation of
Southeast Asian Nations (ASEAN) and the 29th largest in the world.[6]
In 2008, the infant mortality rate, a standard in deter-mining the overall
efficiency of healthcare, was 6.4 per 1000 live births, comparing
favourably with the USA and Western Europe. Similarly, in 2008, life
expect-ancy at birth was 71.6 years for men and 76.4 years for women.[7,8]
Rapid and sustained increases in material wealth have been reflected in the
growing incidence of conditions normally managed almost exclusively in primary
care, including many ‘lifestyle-related’ con-ditions more usually seen in
Europe, Australia and North America. For example, the prevalence of diabetes mellitus
is quoted as being 14.9% of the Malaysian adult population in 2006, nearly
double the prevalence reported a decade previously. This reflects increasing
obesity, but also the genetic susceptibility of a South East Asian population.[9]

As gatekeepers to the healthcare system, Malaysian primary care
practitioners see patients at a point when prevention and effective
treatment are still possible. In this regard, the frequently quoted ‘ecology of
medical care’ has resonance for primary care practitioners in Malaysia.[10]
Not only are doctors in primary care the first to see people when they need
medical advice, but they also provide continuity of care and holistic
management for those who develop chronic and life-limiting illness. Arguably
the most important part of the health service, primary care is provided by both
the public and private sectors. In 2009, there were 5104 private primary care
clinics and 806 publicly funded health clinics. The overall density of primary
care clinics was 2.09 per 10 000 population. The number of private clinics
outnumbered public clinics by 6.3 to 1, whereas the overall primary care
practitioner to population ratio was 2.89 per 10 000 population.[11]

Malaysia
as an exemplar of healthcare in Asia

Malaysians enjoy
excellent health, although at the same time the country spends a modest 4.75%
of GDP on health services.[12] There are compelling reasons why health
innovators and policy makers worldwide may gain from studying the Malaysian
experience, especially in primary care. Primary healthcare has been at the
forefront of health services in Malaysia since 1996.[13] The
government-funded primary health-care sector is the main service provider, as
reflected by the fact that primary healthcare expenditure con-stituted 58.4% of
the total national healthcare budget in 2006.[14] The government is
now proposing a reform of the healthcare finance system. As in neighbouring
Australia, there is a growing recognition of inequity, with some people
experiencing far worse health out-comes than others. While most Malaysians
enjoy excellent access to healthcare, a significant proportion, particularly
those with modest means, residents in the east of the country and aboriginal
Malaysians, have limited access.[15] The have-nots may find themselves
treated in overcrowded, understaffed clinics and ultimately in hospitals
comparable with the poorer parts of Asia and Africa. Most services at public
health clinics are provided by assistant medical officers and nurse
practitioners. The role of nurse practitioners in providing primary care is a
growing feature in Malaysia and is in urgent need of evaluation. There may also
be a separation of prescribing and dispensing services from the existing
dispensing services by the primary care clinics. The financial impact on the
private sector has yet to be established as the income of most private clinics
through loss of dispensing will be threatened. The impact of these financial
changes on healthcare provision has yet to be defined.

Epidemiology in Malaysia features
a double disease burden – conditions that are found in developing countries
including – infectious diseases (HIV, tu-berculosis and dengue) are emerging or
re-emerg-ing.[16,17] Malnutrition and poverty are matched by the
impact of material wealth, including a rising incidence of diabetes, cardiovascular disease, cancer
and mental illness.[18,19] Malaysia has a population that is both ethnically
diverse and ageing. The incidence of con-ditions related to ageing, including
falls and dementia is set to rise steeply. How can Malaysians be supported to
care for a dependent ageing population within the context of a multicultural
population? It is envisaged that the main burden of healthcare for the elderly
will be within primary care.[20] Malaysia is also a multi-ethnic and
multicultural country. This provides a crucible to
explore transcultural issues in healthcare and to study the interaction between
environmental and genetic factors on health. Moreover, with a focus on
traditional and complementary medicine, Malaysian researchers may be able to
define how these treatment choices might influence help-seeking behaviour and
health outcomes in other parts of Asia.

What can
we learn from the Malaysian experience?

There are a
number of areas where the experience in Malaysia may predict future health on
the Asian mainland. How will healthcare reform in Malaysia impact on health
outcomes? Some have questioned the need to reform a system that is already
serving the population well. Others have pointed out that there is evidence
that Malaysians experience poor outcomes in diabetes and heart disease, similar
to neighbouring Australia, and that the demographic changes on the horizon
warrant a proactive approach to reform.[21] These changes are also on
the horizon for other parts of Asia.

The current system where healthcare is highly subsidised in
government-funded health clinics means that many people with chronic and
complex con-ditions are seeking help in the public sector, while those with
acute and self-limiting minor illness are more likely to
present to private medical practi-tioners.[22,23] It remains to be
seen if the trend of utilising
publically funded clinics for the more ex-pensive healthcare conditions can be
sustained with the predicted rise in lifestyle-related chronic illness in an
economically thriving nation. If the public system needs to be reformed, how
will this impact on the affordability of healthcare and how will this be
reflected in the prognosis of chronic conditions? The proposed healthcare
reforms aim to integrate the public and private sectors. Will this lead to a
more cost-effective system with improved quality and equity of care?
Which payment mechanism should be used for effec-tive and
affordable healthcare? Should national in-surance with minimal co-payment
be introduced?

Can the quality of care of publically funded clinics ensure the best
outcomes for patients? As the focus moves from treatment to prevention and
patient empowerment, is the system fit for purpose? The demand for access to
services is predicted to rise, but similarly, changes in the dynamics of the
relationship between doctor and patient are reflected in the trends for greater
litigation and complaint. How will the increasing pace of change in Malaysian
society, with a focus on information technology, be reflected in the redesign
of effective primary care services? For example, what
will be the impact of telehealth? In add-ition, there are now 35 medical
schools in Malaysia. The increase in numbers was an attempt to improve the
patient-to-doctor ratio with the aim of achieving the healthcare status of a
developed country. As most graduates enter primary care, more may be
consider-ing a career abroad as the market becomes saturated. To what extent
will this rise in medical manpower be reflected in improvements to health
outcomes for Malaysians? Will this reduce the discrepancy in medi-cal manpower
between rural and urban areas as well as east and west Malaysia?

The Malaysian government is committed to refur-bishing existing
hospitals, building new hospitals, expanding the number of polyclinics,
improving training and expanding telehealth. However, given the pivotal role of
primary care and without invest-ment in research in that sector, the question
of how the healthcare system can best respond to the needs of a country facing
increasingly rapid growth and econ-omic development has not been answered. The
key questions that primary care research must help to answer include the
following:

How can patients with chronic disease
be served within a population that has such marked ethnic, cultural and social
differences: where poverty exists alongside fabulous wealth, where acute
infectious illness is still a significant healthcare issue and where there is
still systemic inequity of access to health-care?

How will primary care accommodate the
need for healthcare reform? Can the commitment to conti-nuity of care and the
gatekeeper role of the general practitioner be sustained and lead to a more
effec-tive and efficient health system?

•How can the population be more engaged
in healthcare decisions and will patient empower-ment be promoted as a major
issue in healthcare as in the West?

•Is there an adequate understanding of
cultural sensitivities and needs when managing health-related issues in the
population? Cross-cultural research will help to unveil issues pertaining to
communi-cation, health beliefs and help-seeking behaviour, which may be
applicable to the rest of the world as globalisation occurs.

•Will public–private integration lead to
a more efficient healthcare system?

•Will the quality of care be
affected by allowing other than doctors to prescribe?

Malaysia is at the crossroads between the
developing and the developed world; facing east and west; es-pousing new and
old health systems; and confronting new, lifestyle-related chronic conditions
as well as infectious diseases that are more prevalent in devel-oping
countries. There is a growing need to conduct health system research with outcomes that may guide other countries, especially in Asia, where most of the world’s people live.

Forsyth D and Chia YC.
How should Malaysia respond to its ageing society? Medical Journal of Malaysia 2009;64:46–50.

Ministry of Health
Malaysia. National Strategic Plan for Non-communicable Disease (NSPNCD): Medium
term strategic plan to further strengthen the cardiovascular diseases and
diabetes prevention and control program in Malaysia (2010–2014). Ministry of
Health Malaysia: Putrajaya, Malaysia, 2010.